What action should a nurse take when a laboring client exhibits early decelerations?

The correct action in response to early decelerations during labor is to document the findings. Early decelerations are typically associated with head compression during contractions and are generally considered a benign and expected finding in the normal course of labor. Proper documentation is crucial, as it provides a record of the fetal heart rate pattern and the context of the labor process.

This documentation aids in monitoring trends and ensures that any significant changes or concerns are noted for further evaluation and management if necessary. It also serves as a legal record of the care provided and the observations made by the nursing staff.

While actions such as repositioning the client may help alleviate pressure on the umbilical cord if present, in the case of early decelerations, this is often optional and may not always be necessary. Discontinuing oxytocin infusion or preparing for an amnioinfusion are more invasive responses typically reserved for situations where there are signs of distress or other concerning patterns in fetal heart rate monitoring. Therefore, initial documentation remains the priority when early decelerations are present and no other signs of fetal distress are observed.